Provider Demographics
NPI:1992304067
Name:DANIELSON, TIMOTHY WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:WAYNE
Other - Last Name:DANIELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:636 COUNTY HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53021-9610
Mailing Address - Country:US
Mailing Address - Phone:262-343-1417
Mailing Address - Fax:
Practice Address - Street 1:4433 VANGUARD DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-6067
Practice Address - Country:US
Practice Address - Phone:920-459-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8932-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist